Trichotillomania

September 29, 2011

Trichotillomania, a disorder of chronic hair pulling, is classified in the Diagnostic Statistical Manual of Mental Disorders, fourth edition (DSM-IV) as an impulse control disorder. The individual experiences a recurrent and generally irresistible urge to engage in hair pulling, resulting in significant hair loss. This may occur at multiple sites, most often on the scalp, but also on the eyebrows, eyelashes, pubic area, underarm (axillary area), and beard. A sense of tension is experienced just before the hair pulling or if the individual resists pulling. As the hair is pulled, the patient experiences a sense of pleasure, gratification, or relief. To be considered as trichotillomania in the DSM-IV, hair pulling must not be caused by any medical, derma-tological, or psychiatric disorder and should cause clinically significant distress and impairment in social, occupational, or other important areas of functioning.

Trichotillomania was previously considered a rare condition. Recent studies suggest a lifetime prevalence of 2-3%, children more often than adults and female: male ratio of 7:1 or higher, perhaps because females are more likely to seek medical care. It predominantly develops in the first two decades of life with a mean age of onset at 13 years. As with obsessive-compulsive disorder (OCD), patients with trichotillomania are secretive about their symptoms and tend to disguise hair loss with hair styles and hair prosthetics. They may be embarrassed by the hair loss or reluctant to seek treatment, thus delaying recognition of the disorder. The course of the disease varies, from chronic to episodic to permanent remission. Two styles of hair pulling have been proposed. Patients with a “focused style” center their complete attention on the pulling activity. The majority of patients have an “automatic style” and practice hair pulling parallel to other situations like reading or watching television. Hair pullers often describe a combination of both styles.

Hair pulling results in alopecia (hairless areas on the scalp), which occurs in irregular patches and is identifiable by its distinctive pathology on scalp biopsy. On skin surface (histopathologic) examination, there is no scarring, inflammation, or abnormalities of the scalp or skin. Short broken strands are mixed with a few longer, normal hairs. Hair pulling of trichotillomania is not reported to be painful. The diagnostic evaluation of trichotillomania includes a number of different medical conditions and psychiatric pathology like OCD. Patchy hair loss can be seen in patients with syphilis, tinea capitis (head lice), and systemic lupus erythematosus (a disorder of the immune system), but is usually accompanied by inflammation. Alopecia can cause either generalized or patchy hair loss. When patches occur, they are sharply bounded and lack any normal hair. Unlike patients with trichotillomania, medical conditions like hypothyroidism and lithium toxicity cause generalized hair loss. Hair pulling of OCD is performed consciously to avoid anxiety and may be associated with other rituals. Hair pulling of trichotillomania, on the other hand, is pleasurable, performed in response to anxiety, and is associated with denial and minimum awareness.

Medical complications of trichotillomania can include infection and scarring at the site, change in color or texture of the hair, slowed or stopped hair growth, and indirect complications leading to fear of embarrassment such as avoiding physical examinations, and the like. Trichophagy or hair ingestion may accompany hair pulling, sometimes leading to development of a trichobezoar (hairball). Anorexia (lack of appetite), stomach pain, obstruction, anemia (low blood count), and malnutrition may develop secondary to trichobezoar formation. Repetitive arm and hand movements involved in hair pulling can cause carpal tunnel syndrome and other neuromuscular disorders. Psychiatric comorbidities (conditions occurring at the same time) include major depression, generalized anxiety disorder, eating disorder, Tourette’s syndrome (a syndrome of involuntary tics), body dysmorphic disorder (abnormal perception of body form), alcohol or other substance dependence and abuse, simple or social phobia. Prevalence of OCD in these patients is extremely high (13%), as compared to the general population (2-3%).

Although trichotillomania may be multidetermined (caused by multiple factors), its onset has been linked to stressful situations in more than 25% of all cases. Disturbances in mother-child relationships, fear of being left alone, and recent object loss are often cited as important contributing factors. Neurobiological investigations show evidence of abnormal patterns of brain neurotransmitters (serotonin) and involvement of the parts of the brain called the basal ganglia and frontal lobes, similar to that seen in people with OCD and Tourette’s syndrome. Baseline levels of amino acids in spinal fluid (cerebrol spinal fluid 5-hydroxyindoleacetic acid levels) in individuals with trichotillomania seem to correlate with response to serotonin reuptake inhibitors (some types of antidepressant medications). Severity of assessment of trichotillomania can be assessed by different questionnaires: Trichotillomania Questionnaire, Massachusetts General Hospital Hairpulling Scale, Tricho-tillomania Symptom Severity Scale, Trichotillomania Impairment Scale, and Physician’s Rating of Clinical Progress Scale.

Treatment options include medication, behavioral techniques, and hypnosis. Selective serotonin reuptake inhibitors (SSRI) remain the most popular pharmacological intervention and have the most evidence-based support. Very scientifically rigorous research studies (double-blind placebo-controlled studies) have documented positive treatment responses to the antidepres-sant medications clomipramine, fluvoxamine, and fluoxetine. Lithium may lead to decreased hair pulling and mild to moderate hair growth but relapse often occurs. Lithium can cause hair loss by itself, especially if there is a coexistent zinc deficiency. Treatment with naltrexone has shown mixed results and there are case reports documenting efficacy of buspirone, lev-onorgestrel, and fenfluramine. Neuroleptics have been successfully used in cases of hair pulling associated with severe mental disorders such as autism and with conditions in which individuals have conditions of abnormal perception, such as psychosis.

The most widely studied, preferred, and popular treatment is the behavioral technique of habit reversal. It includes the principle of awareness training, which consists of monitoring all urges to pull, actual occurrences of pulling, and feelings immediately before and after the pulling. Habit reversal also includes competing response training which requires substituting an incompatible behavior like clenching an object when experiencing the urge to pull out hair. Relaxation training, overcorrection like extensive hair brushing, and prevention training are other components of behavioral therapy. Hypnosis may be used independently or as complementing other techniques. The focus is on helping the individual become more aware of what he or she is doing and reinforcing behavioral control over hair pulling. In addition, cognitive-behavioral therapy can assist the patient in counteracting maladaptive thought patterns. Ongoing research is hopeful with up-to-date information available online through the Trichotillomania Learning Center (http://www.trich.org).